CLM-2026-030339
Meadow Family Practice, Family Medicine. Service 2026-09-21 at office (POS 11). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Jeremy Jacobs
- Member ID
- UHC-82894-81
- Date of birth
- 1953-11-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422467
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6781
- Coverage period
- 2022-01-01 to 2026-03-07
- Deductible
- $1,567.17 of $2,500.0063%
- Out-of-pocket maximum
- $1,464.36 of $5,000.0029%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 8614941473
- Network
- In network
- Rendering NPI
- 6145281534
- Location
- Atlanta, GA · TIN 64-8981661
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $290.00 | $179.80 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $23.00 | $14.26 | — | — | DeniedCO27 |
| Totals | $313.00 | $194.06 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-116030
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-046433 (provisional, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-21 is after coverage terminated on 2026-03-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Family Practice (8614941473). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Family Practice2026-09-21 15:02
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-10-14 05:49
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-14 08:26
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-21 is after coverage terminated on 2026-03-07.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.